Клиническая история болезни

СЕВЕРО-ЗАПАДНЫЙ ГОСУДАРСТВЕННЫЙ

МЕДИЦИНСКИЙ УНИВЕРСИТЕТ

Им. И.И.МЕЧНИКОВА

КАФЕДРА ХИРУРГИЧЕСКИХ БОЛЕЗНЕЙ №1

С КУРСОМ ДЕСКОЙ ХИРУРГИИ ИМ. ПРОФ. В.А. ОППЕЛЯ

АКАДЕМИЧЕСКАЯ ИСТОРИЯ БОЛЕЗНИ

САНКТ – ПЕТЕРБУРГ

-2012-

СХЕМА ИСТОИИ БОЛЕЗНИ

Титульный лист (отдельная страница)

1. Паспортная часть

2. Жалобы больного; опрос по системам органов (записываются только патологические

отклонения)

3. Anamnesis morbi

4. Anamnesis vitae 4.1. Перенесённые заболевания и травмы

4.2. Гинекологический анамнез

4.3. Эпиданамнез

4.4. Аллергологический анамнез

4.5. Страховой анамнез

5. Status praesens objectivus

6. Осмотр по системам 6.1. Сердечно-сосудистая система

6.2. Дыхательная система

6.3. Желудочно-кишечный тракт

6.4. Мочевыделительная система

6.5. Нервная система

6.6. Опорно-двигательная система

6.7. Эндокринная система

6.8. Status localis

7. Предварительный диагноз и его обоснование

8. План обследования больного

9. Данные лабораторных и инструментальных исследований, заключения консультантов

10. Дифференциальный диагноз

11. Клинический диагноз и его обоснование

12. Изложение данных о сущности заболевания

13. Способы лечения данного заболевания

14. Лечение больного

15. Прогноз

16. Профилактика (первичная и вторичная)

17. Дневник курации

18. Эпикриз

19. Библиография

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СЕВЕРО-ЗАПАДНЫЙ ГОСУДАРСТВЕННЫЙ

МЕДИЦИНСКИЙ УНИВЕРСИТЕТ им. И.И.МЕЧНИКОВА

КАФЕДРА ХИРУРГИЧЕСКИХ БОЛЕЗНЕЙ №1

С КУРСОМ ДЕСКОЙ ХИРУРГИИ ИМ. ПРОФ. В.А. ОППЕЛЯ

КЛИНИЧЕСКАЯ ИСТОРИЯ БОЛЕЗНИ

Фамилия, имя, отчество: _______________________________________________________________

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Возраст: _____________________________________________________________________________

Постоянное место жительства: __________________________________________________________

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Место работы, профессия: _____________________________________________________________

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Кем направлен больной: _______________________________________________________________

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Диагноз клинический: _________________________________________________________________

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Операция: (название, дата) _____________________________________________________________

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Начало курации: ________________________ Завершение курации: _________________________

Куратор: студент ________________ группы ___________________________ факультета

Ф.И.О.: ______________________________________________________________________________

Преподаватель: ___________________________________________________________________

ЗАВЕДУЮЩИЙ КАФЕДРОЙ – д.м.н., профессор Э.Э. Топузов

2. ЖАЛОБЫ больного: ________________________________________________________________

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3. ANAMNESIS MORBI: (изложить в хронологическом порядке основные моменты развития заболевания, виды полученного консервативного и оперативного лечения и его эффект (при оперативном лечении – название операции, дата, где поведена) ______________________________

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18. ЭПИКРИЗ: (краткое содержание анамнеза, данные исследований, оперативное вмешательство, течение послеоперационного периода, прогноз для жизни и трудоспособности, рекомендации) ___

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_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. ANAMNESIS VITAE с учётом социального положения в настоящее время (условия быта, члены семьи, с которыми живёт больной; характер работы в настоящее время). Вредные привычки: _____________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.1. ПЕРЕНЕСЁННЫЕ ЗАБОЛЕВАНИЯ И ТРАВМЫ (в хронологии): _______________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.2. ГИНЕКОЛОГИЧЕСКИЙ АНАМНЕЗ: начало месячных, число беременностей, родов, абортов, период менопаузы _____________________________________________________________

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4.4. АЛЛЕРГОЛОГИЧЕСКИЙ АНАМНЕЗ: непереносимость лекарственных средств и пищевых продуктов (указать характер реакции организма) __________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.5. СТРАХОВОЙ АНАМНЕЗ: количество дней, месяцев болезни по листу нетрудоспособности за последние 12 календарных месяцев; наличие инвалидности и дата её получения: _____________

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5. STATUS PRAESENS OBJECTIVUS.

Общая характеристика больного: оценка общего состояния (удовлетворительное, средней тяжести, тяжёлое, терминальное) ________________________________________________________________

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Положение в постели (активное, пассивное, вынужденное)__________________________________

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Кожные покровы (цвет, влажность, подкожные кровоизлияния, отёки, раны, рубцы, свищи), периферические лимфоузлы, упитанность, тип телосложения ________________________________

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6. ОБСЛЕДОВАНИЕ ПО СИСТЕМАМ И ОРГАНАМ.

6.1. СЕРДЕЧНО-СОСУДИСТАЯ СИСТЕМА: общая характеристика пульса, сердечных сокращений, АД. Границы сердечной тупости при наличии патологии сердечно-сосудистой системы _____________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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17. ДНЕВНИК КУРАЦИИ: (Состояние больного, пульс, тоны сердца, АД. Тип дыхания, наличие хрипов, ЧД. Пальпация живота, физиологические отправления (обязательное отражение динамики состояния, подробное описание изменений; назначения) ____________________________________

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6.2. ДЫХАТЕЛЬНАЯ СИСТЕМА: частота дыхания, наличие хрипов, характеристика типов дыхания _____________________________________________________________________________

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6.3. ЖЕЛУДОЧНО-КИШЕЧНЫЙ ТРАКТ: Осмотр полости рта, формула зубов. Описать слизистую языка. Данные пальпации и перкуссии печени и органов брюшной полости. Характер и частота стула _________________________________________________________________________

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6.4. МОЧЕВЫДЕЛИТЕЛЬНАЯ СИСТЕМА: _______________________________________________

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6.5. НЕРВНАЯ СИСТЕМА: Сознание и адекватность поведения. Периферическая иннервация. Чувствительные и двигательные расстройства. ____________________________________________

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15. ПРОГНОЗ: ________________________________________________________________________

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16. ПРОФИЛАКТИКА: (первичная и вторичная) ___________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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6.6. ОПОРНО-ДВИГАТЕЛЬНАЯ СИСТЕМА: Осмотр больного стоя и лёжа в обнажённом виде. Состояние кожных покровов (чистые, наличие пигментных пятен, гипертрихоза, ихтиоза)________

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6.7. ЭНДОКРИННАЯ СИСТЕМА: _______________________________________________________

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6.8. STATUS LOCALIS: ________________________________________________________________

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14. ЛЕЧЕНИЕ БОЛЬНОГО: _____________________________________________________________

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13. СПОСОБЫ ЛЕЧЕНИЯ данного заболевания: ___________________________________________

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7. ПРЕДВАРИТЕЛЬНЫЙ ДИАГНОЗ и его обоснование: ____________________________________

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8. ПЛАН ОБСЛЕДОВАНИЯ БОЛЬНОГО: ________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. ДАННЫЕ ЛАБОРАТОРНЫХ И ИНСТРУМЕНТАЛЬНЫХ ИССЛЕДОВАНИЙ, ЗАКЛЮЧЕНИЯ КОНСУЛЬТАНТОВ

Клинический анализ крови: ____________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Общий анализ мочи: ___________________________________________________________________

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Биохимические исследования:

Билирубин крови: __________________